Rates of women who are opting for preventive mastectomies, such as Angeline Jolie, have increased by an estimated 50 percent in recent years, experts say. But many doctors are puzzled because the operation doesn't carry a 100 percent guarantee, it's major surgery -- and women have other options, from a once-a-day pill to careful monitoring.

A year after the Medicare overhaul became law, the Bush administration is struggling to get low-income older and disabled Americans signed up for a drug discount card that comes with $1,200 in aid between now and 2006.

"Whether we get two or three or 20, we don't worry about it. There's no silver bullet," said Fumich, who directs the Greater Cleveland Access to Benefits Coalition and the city's Department of Aging.

Wednesday is the first anniversary of the Medicare prescription drug law that Bush and Republicans made their top legislative priority leading up to the 2004 election season.

But the administration is finding it difficult to get the discount cards in the hands of those who — supporters and detractors alike agree — are the people who could gain the most from them.

About 1.5 million low-income Americans have signed up for a card, Medicare chief Mark McClellan said. The administration had forecast that more than three times that many would enroll in the program by year's end. More than 7 million people are eligible.

Highlighting the difficulty, the private companies that sponsor the drug cards sent nearly 2 million cards to low-income people in October and asked them to make just one phone call to activate the card and government assistance. Only 100,000 have done so, McClellan said.

"The evidence is becoming overwhelming that the program does not work," said Robert Hayes, president of the Medicare Rights Center, which is part of a coalition of civic groups trying to get cards to people who qualify for the assistance.

Complexity prompts skepticism
The results of the discount card program are especially troubling because much more generous assistance awaits the poor in the Medicare prescription drug benefit, known as Medicare Part D, that begins in 2006. Drug bills can be cut by more than 80 percent on average, according to a recent Kaiser Family Foundation study, but only for those who sign up.

"Part D is going to be even more complex," said James Firman, president of the National Council on the Aging and the leader of the Access to Benefits Coalition.

The low take-up rate is endemic to government aid programs, in which just one in five people typically enroll after simply being told they are eligible, Firman said.

"People are skeptical. The benefits are complex and people often have low literacy. The process of deciding what to do and filling out the paperwork is hard work," he said.

Hayes and other advocates say the administration is ignoring this history and taking the wrong approach by insisting that enrollment be voluntary. Instead, they say, the government should enroll everyone eligible, and those who object should be allowed to opt out of the program.

McClellan and other officials have been unstinting in their defense of the law, pointing out that older Americans without drug insurance will be getting help for the first time while also noting that Medicare is beefing up prevention benefits.

Nearly 6 million have signed up for discount cards, designed as a bridge to the Medicare prescription drug benefit that begins in 2006. The cards offer price breaks of 10 percent to 25 percent, on average, for those who do not receive the subsidy.

Even McClellan, however, acknowledged the difficulty of reaching the poor in virtually all government programs.

Difficulty for all
"The unfortunate truth is ... it can be really hard to find and then get enrolled and get helped the people the programs are intended to help," he told a gathering of people who are trying to boost low-income enrollment.

In some cases, groups are sending completed forms to people, marking a red X on the signature line and providing a stamped, addressed envelope. Even then, some people do nothing.

Fumich's goal is to sign up 1,700 people in the six-county area in and around Cleveland by the end of the year. People who enroll before Dec. 31 can carry over this year's $600 subsidy. But people who sign up on Jan. 1 or later will get no more than $600 in all.